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Designing Effective Alcohol Warnings: Consumer Reactions to Icons and Health Topics

  • Anna H. Grummon
    Correspondence
    Address correspondence to: Anna H. Grummon, PhD, Department of Nutrition, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston MA 20115.
    Affiliations
    Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts

    Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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  • Phoebe R. Ruggles
    Affiliations
    Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
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  • Thomas K. Greenfield
    Affiliations
    Alcohol Research Group, Public Health Institute, Emeryville, California
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  • Marissa G. Hall
    Affiliations
    Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina

    Carolina Population Center, The University of North Carolina Chapel Hill, Chapel Hill, North Carolina

    Lineberger Comprehensive Cancer Center, The University of North Carolina Chapel Hill, Chapel Hill, North Carolina
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Published:October 26, 2022DOI:https://doi.org/10.1016/j.amepre.2022.09.006

      Introduction

      New warning labels for alcohol could reduce alcohol-related health harms. This study examined consumer responses to alcohol warnings with different designs.

      Methods

      A national sample of 3,051 U.S. adults completed an online survey in August 2021. Participants were randomized to 1 of 4 warning topics (addiction, liver damage, early death, or colon cancer). Participants viewed 3 labels presented in random order: 2 types of warning labels (text-only and icon) showing a newly developed warning message about their assigned topic and a text-only control label showing a neutral message. Participants rated each label on effectiveness at discouraging alcohol consumption (primary outcome) and attention (secondary outcome) using 1-to-5‒point Likert-type scales. Participants also rated warnings with different causal language variants (e.g., “increases the risk of”, “contributes to”) and marker words (e.g., “WARNING”, “SURGEON GENERAL WARNING”).

      Results

      Both the text-only and icon warnings were perceived as more effective (average differential effects=0.79 and 0.86, respectively) and more attention grabbing (average differential effects=0.43 and 0.69, respectively) than control labels (all p<0.001). The icon warnings were rated as more effective and attention grabbing than the text-only warnings (average differential effects=0.07 and 0.27, respectively, both p<0.001). Although all warning topics outperformed the control messages, warnings about addiction were rated as less effective and attention grabbing than warnings about the other topics. A majority (60%) of participants selected “increases the risk of” as the most discouraging causal variant, and a plurality (47%) selected “SURGEON GENERAL WARNING” as the most discouraging marker word.

      Conclusions

      New alcohol warnings could discourage alcohol consumption, especially if warnings include icons.
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      REFERENCES

        • Murray CJ
        • Atkinson C
        • Bhalla K
        • et al.
        The state of U.S. health, 1990–2010: burden of diseases, injuries, and risk factors.
        JAMA. 2013; 310: 591-608https://doi.org/10.1001/jama.2013.13805
        • Esser MB
        • Sherk A
        • Liu Y
        • et al.
        Deaths and years of potential life lost from excessive alcohol use–United States, 2011–2015.
        MMWR Morb Mortal Wkly Rep. 2020; 69: 1428-1433https://doi.org/10.15585/mmwr.mm6939a6
      1. Deaths from excessive alcohol use in the United States.
        Centers for Disease Control and Prevention, 2022 (Updated July 6, 2022. Accessed April 26)
        • LoConte NK
        • Brewster AM
        • Kaur JS
        • Merrill JK
        • Alberg AJ.
        Alcohol and cancer: a statement of the American Society of Clinical Oncology.
        J Clin Oncol. 2018; 36: 83-93https://doi.org/10.1200/JCO.2017.76.1155
        • Rumgay H
        • Shield K
        • Charvat H
        • et al.
        Global burden of cancer in 2020 attributable to alcohol consumption: a population-based study.
        Lancet Oncol. 2021; 22: 1071-1080https://doi.org/10.1016/S1470-2045(21)00279-5
        • Nelson DE
        • Jarman DW
        • Rehm J
        • et al.
        Alcohol-attributable cancer deaths and years of potential life lost in the United States.
        Am J Public Health. 2013; 103: 641-648https://doi.org/10.2105/AJPH.2012.301199
        • WHO
        Global Status report on alcohol and health 2018.
        WHO, Geneva, Switzerland2018 (Published. Accessed November 10, 2021)
        • Mostofsky E
        • Mukamal KJ
        • Giovannucci EL
        • Stampfer MJ
        • Rimm EB.
        Key findings on alcohol consumption and a variety of health outcomes from the Nurses’ Health Study.
        Am J Public Health. 2016; 106: 1586-1591https://doi.org/10.2105/AJPH.2016.303336
        • International Agency for Research on Cancer
        Personal habits and indoor combustions.
        International Agency for Research on Cancer, Lyon, France2012 (Published. Accessed July 7, 2022)
        • Cogliano VJ
        • Baan R
        • Straif K
        • et al.
        Preventable exposures associated with human cancers.
        J Natl Cancer Inst. 2011; 103: 1827-1839https://doi.org/10.1093/jnci/djr483
        • Rehm J
        • Patra J
        • Brennan A
        • et al.
        The role of alcohol use in the aetiology and progression of liver disease: a narrative review and a quantification.
        Drug Alcohol Rev. 2021; 40: 1377-1386https://doi.org/10.1111/dar.13286
        • Boersma P
        • Villarroel MA
        • Vahratian A.
        Heavy drinking among U.S. adults. 2018.
        Centers for Disease Control and Prevention, Atlanta, GA2020 (Published August 18. Accessed May 12, 2022)
        • WHO
        Health warning labels on alcoholic beverages: opportunities for informed and healthier choices.
        WHO, Geneva, Switzerland2022 (Published March 22. Accessed July 5, 2022)
        • Stockwell T
        • Solomon R
        • O'Brien P
        • Vallance K
        • Hobin E
        Cancer warning labels on alcohol containers: a consumer's right to know, a government's responsibility to inform, and an industry's power to thwart.
        J Stud Alcohol Drugs. 2020; 81: 284-292https://doi.org/10.15288/jsad.2020.81.284
        • Greenfield TK
        • Graves KL
        • Kaskutas LA.
        Long-term effects of alcohol warning labels: findings from a comparison of the United States and Ontario, Canada.
        Psychol Mark. 1999; 16: 261-282https://doi.org/10.1002/(SICI)1520-6793(199905)16:3≤261::AID-MAR5≥3.0.CO;2-Z
        • Jones D
        • Moodie C
        • Purves RI
        • Fitzgerald N
        • Crockett R.
        Health information, messaging and warnings on alcohol packaging: a focus group study with young adult drinkers in Scotland.
        Addict Res Theor. 2021; 29: 469-478https://doi.org/10.1080/16066359.2021.1884229
        • Hammond D.
        Health warning messages on tobacco products: a review.
        Tob Control. 2011; 20: 327-337https://doi.org/10.1136/tc.2010.037630
        • Al-Hamdani M
        • Smith SM.
        Alcohol warning label perceptions: do warning sizes and plain packaging matter?.
        J Stud Alcohol Drugs. 2017; 78: 79-87https://doi.org/10.15288/jsad.2017.78.79
        • Noar SM
        • Francis DB
        • Bridges C
        • Sontag JM
        • Ribisl KM
        • Brewer NT.
        The impact of strengthening cigarette pack warnings: systematic review of longitudinal observational studies.
        Soc Sci Med. 2016; 164: 118-129https://doi.org/10.1016/j.socscimed.2016.06.011
        • Brewer NT
        • Hall MG
        • Noar SM
        • et al.
        Effect of pictorial cigarette pack warnings on changes in smoking behavior: a randomized clinical trial.
        JAMA Intern Med. 2016; 176: 905-912https://doi.org/10.1001/jamainternmed.2016.2621
        • Donnelly GE
        • Zatz LY
        • Svirsky D
        • John LK.
        The effect of graphic warnings on sugary-drink purchasing.
        Psychol Sci. 2018; 29: 1321-1333https://doi.org/10.1177/0956797618766361
        • Brewer NT
        • Jeong M
        • Hall MG
        • et al.
        Impact of E-cigarette health warnings on motivation to vape and smoke.
        Tob Control. 2019; 28: e64-e70https://doi.org/10.1136/tobaccocontrol-2018-054878
        • Monk RL
        • Westwood J
        • Heim D
        • Qureshi AW.
        The effect of pictorial content on attention levels and alcohol-related beliefs: an eye-tracking study.
        J Appl Soc Psychol. 2017; 47: 158-164https://doi.org/10.1111/jasp.12432
        • Roberto CA
        • Ng SW
        • Ganderats-Fuentes M
        • et al.
        The influence of front-of-package nutrition labeling on consumer behavior and product reformulation.
        Annu Rev Nutr. 2021; 41: 529-550https://doi.org/10.1146/annurev-nutr-111120-094932
        • Noar SM
        • Hall MG
        • Francis DB
        • Ribisl KM
        • Pepper JK
        • Brewer NT.
        Pictorial cigarette pack warnings: a meta-analysis of experimental studies.
        Tob Control. 2016; 25: 341-354https://doi.org/10.1136/tobaccocontrol-2014-051978
      2. Alcoholic Beverage Labeling Act of 1988. GovInfo.https://www.govinfo.gov/content/pkg/USCODE-2014-title27/pdf/USCODE-2014-title27-chap8-subchapII.pdf. Updated October 22, 1988. Accessed July 7, 2022.

        • Wilkinson C
        • Room R.
        Warnings on alcohol containers and advertisements: international experience and evidence on effects.
        Drug Alcohol Rev. 2009; 28: 426-435https://doi.org/10.1111/j.1465-3362.2009.00055.x
        • Hobin E
        • Schoueri-Mychasiw N
        • Weerasinghe A
        • et al.
        Effects of strengthening alcohol labels on attention, message processing, and perceived effectiveness: a quasi-experimental study in Yukon, Canada.
        Int J Drug Policy. 2020; 77102666https://doi.org/10.1016/j.drugpo.2020.102666
        • Schoueri-Mychasiw N
        • Weerasinghe A
        • Vallance K
        • et al.
        Examining the impact of alcohol labels on awareness and knowledge of national drinking guidelines: a real-world study in Yukon, Canada.
        J Stud Alcohol Drugs. 2020; 81: 262-272https://doi.org/10.15288/jsad.2020.81.262
        • Zhao J
        • Stockwell T
        • Vallance K
        • Hobin E.
        The effects of alcohol warning labels on population alcohol consumption: an interrupted time series analysis of alcohol sales in Yukon, Canada.
        J Stud Alcohol Drugs. 2020; 81: 225-237https://doi.org/10.15288/jsad.2020.81.225
        • Clarke N
        • Blackwell AKM
        • De-Loyde K
        • et al.
        Health warning labels and alcohol selection: a randomised controlled experiment in a naturalistic shopping laboratory.
        Addiction. 2021; 116: 3333-3345https://doi.org/10.1111/add.15519
        • Wigg S
        • Stafford LD.
        Health warnings on alcoholic beverages: perceptions of the health risks and intentions towards alcohol consumption.
        PLoS One. 2016; 11e0153027https://doi.org/10.1371/journal.pone.0153027
        • Clarke N
        • Pechey E
        • Mantzari E
        • et al.
        Impact of health warning labels communicating the risk of cancer on alcohol selection: an online experimental study.
        Addiction. 2021; 116: 41-52https://doi.org/10.1111/add.15072
        • Clarke N
        • Pechey E
        • Kosīte D
        • et al.
        Impact of health warning labels on selection and consumption of food and alcohol products: systematic review with meta-analysis.
        Health Psychol Rev. 2021; 15: 430-453https://doi.org/10.1080/17437199.2020.1780147
        • Stafford LD
        • Salmon J.
        Alcohol health warnings can influence the speed of consumption.
        Z Gesundh Wiss. 2017; 25: 147-154https://doi.org/10.1007/s10389-016-0770-3
        • Hall MG
        • Grummon AH
        • Higgins ICA
        • et al.
        The impact of pictorial health warnings on purchases of sugary drinks for children: a randomized controlled trial.
        PLoS Med. 2022; 19e1003885https://doi.org/10.1371/journal.pmed.1003885
        • Pechey E
        • Clarke N
        • Mantzari E
        • et al.
        Image-and-text health warning labels on alcohol and food: potential effectiveness and acceptability.
        BMC Public Health. 2020; 20: 376https://doi.org/10.1186/s12889-020-8403-8
        • Pettigrew S
        • Jongenelis M
        • Chikritzhs T
        • et al.
        Developing cancer warning statements for alcoholic beverages.
        BMC Public Health. 2014; 14: 786https://doi.org/10.1186/1471-2458-14-786
        • Jongenelis MI
        • Pratt IS
        • Slevin T
        • Chikritzhs T
        • Liang W
        • Pettigrew S.
        The effect of chronic disease warning statements on alcohol-related health beliefs and consumption intentions among at-risk drinkers.
        Health Educ Res. 2018; 33: 351-360https://doi.org/10.1093/her/cyy025
        • Hassan LM
        • Parry S
        • Shiu E.
        Exploring responses to differing message content of pictorial alcohol warning labels.
        Int J Consum Stud. 2022; (In press. Online January 27)https://doi.org/10.1111/ijcs.12779
        • Kokole D
        • Anderson P
        Jané-Llopis E. Nature and potential impact of alcohol health warning labels: a scoping review.
        Nutrients. 2021; 13: 3065https://doi.org/10.3390/nu13093065
        • Jeong M
        • Zhang D
        • Morgan JC
        • et al.
        Similarities and differences in tobacco control research findings from convenience and probability samples.
        Ann Behav Med. 2019; 53: 476-485https://doi.org/10.1093/abm/kay059
        • Rehm J.
        The risks associated with alcohol use and alcoholism.
        Alcohol Res Health. 2011; 34: 135-143
      3. Alcohol use and your health.
        Centers for Disease Control and Prevention, 2022 (Updated April 6, 2022. Accessed March 28)
        • Greenfield TK
        • Ye Y
        • Bond J
        • et al.
        Risks of alcohol use disorders related to drinking patterns in the US general population.
        J Stud Alcohol Drugs. 2014; 75: 319-327https://doi.org/10.15288/jsad.2014.75.319
        • Roerecke M
        • Vafaei A
        • Hasan OSM
        • et al.
        Alcohol consumption and risk of liver cirrhosis: a systematic review and meta-analysis.
        Am J Gastroenterol. 2019; 114: 1574-1586https://doi.org/10.14309/ajg.0000000000000340
        • GBD 2016 Alcohol Collaborators
        Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.
        Lancet. 2018; 392: 1015-1035https://doi.org/10.1016/S0140-6736(18)31310-2
        • Wood AM
        • Kaptoge S
        • Butterworth AS
        • et al.
        Risk thresholds for alcohol consumption: combined analysis of individual-participant data for 599 912 current drinkers in 83 prospective studies [published correction appears in Lancet. 2018;391(10136):2212].
        Lancet. 2018; 391: 1513-1523https://doi.org/10.1016/S0140-6736(18)30134-X
        • Rehm J
        • Greenfield TK
        • Kerr W.
        Patterns of drinking and mortality from different diseases–an overview.
        Contemp Drug Probl. 2006; 33: 205-235https://doi.org/10.1177/009145090603300203
        • McNabb S
        • Harrison TA
        • Albanes D
        • et al.
        Meta-analysis of 16 studies of the association of alcohol with colorectal cancer.
        Int J Cancer. 2020; 146: 861-873https://doi.org/10.1002/ijc.32377
        • Choi YJ
        • Myung SK
        • Lee JH.
        Light alcohol drinking and risk of cancer: a meta-analysis of cohort studies.
        Cancer Res Treat. 2018; 50: 474-487https://doi.org/10.4143/crt.2017.094
        • Bagnardi V
        • Rota M
        • Botteri E
        • et al.
        Alcohol consumption and site-specific cancer risk: a comprehensive dose-response meta-analysis.
        Br J Cancer. 2015; 112: 580-593https://doi.org/10.1038/bjc.2014.579
        • Rohde JA
        • Noar SM
        • Mendel JR
        • et al.
        E-cigarette health harm awareness and discouragement: implications for health communication.
        Nicotine Tob Res. 2020; 22: 1131-1138https://doi.org/10.1093/ntr/ntz194
        • Carl AE
        • Taillie LS
        • Grummon AH
        • et al.
        Awareness of and reactions to the health harms of sugary drinks: an online study of U.S. parents.
        Appetite. 2021; 164105234https://doi.org/10.1016/j.appet.2021.105234
        • Hall MG
        • Grummon AH
        • Lazard AJ
        • Maynard OM
        • Taillie LS.
        Reactions to graphic and text health warnings for cigarettes, sugar-sweetened beverages, and alcohol: an online randomized experiment of U.S. adults.
        Prev Med. 2020; 137106120https://doi.org/10.1016/j.ypmed.2020.106120
        • Taillie LS
        • Prestemon CE
        • Hall MG
        • Grummon AH
        • Vesely A
        • Jaacks LM.
        Developing health and environmental warning messages about red meat: an online experiment.
        PLoS One. 2022; 17e0268121https://doi.org/10.1371/journal.pone.0268121
        • Pettigrew S
        • Jongenelis MI
        • Glance D
        • et al.
        The effect of cancer warning statements on alcohol consumption intentions.
        Health Educ Res. 2016; 31: 60-69https://doi.org/10.1093/her/cyv067
        • Brewer NT
        • Jeong M
        • Mendel JR
        • et al.
        Cigarette pack messages about toxic chemicals: a randomised clinical trial.
        Tob Control. 2019; 28: 74-80https://doi.org/10.1136/tobaccocontrol-2017-054112
        • Hall MG
        • Lazard AJ
        • Grummon AH
        • et al.
        Designing warnings for sugary drinks: a randomized experiment with Latino parents and non-Latino parents.
        Prev Med. 2021; 148106562https://doi.org/10.1016/j.ypmed.2021.106562
      4. Cabrera M, Machín L, Arrúa A, et al. Nutrition warnings as front-of-pack labels: influence of design features on healthfulness perception and attentional capture. Public Health Nutr. 2017;20(18):3360–3371. https://doi.org/10.1017/S136898001700249X.

      5. Article 42: Sugar-Sweetened Beverage Warning Ordinance, City and County of San Francisco (2021). https://codelibrary.amlegal.com/codes/san_francisco/latest/sf_health/0-0-0-58530#JD_4203. Accessed July 7, 2022.

        • Grummon AH
        • Hall MG
        • Taillie LS
        • Brewer NT.
        How should sugar-sweetened beverage health warnings be designed? A randomized experiment.
        Prev Med. 2019; 121: 158-166https://doi.org/10.1016/j.ypmed.2019.02.010
        • Hall MG
        • Grummon AH
        • Maynard OM
        • Kameny MR
        • Jenson D
        • Popkin BM.
        Causal language in health warning labels and U.S. adults’ perception: a randomized experiment.
        Am J Public Health. 2019; 109: 1429-1433https://doi.org/10.2105/AJPH.2019.305222
      6. FDA requires new health warnings for cigarette packages and advertisements.
        Food and Drug Administration, 2020 (Updated March 17. Accessed July 1, 2022)
      7. Countries with mandatory or voluntary interpretative labels on packaged foods and drinks.
        Global Food Research Program, 2021 (Updated September. Accessed June 12, 2022)
      8. Sugar-Sweetened Beverages: Safety Warnings, SB-347, California Legislative (2019–2020). http://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201920200SB347. Accessed February 27, 2019.

        • Riley MW
        • Cochran DJ
        • Ballard JL.
        An investigation of preferred shapes for warning labels.
        Hum Factors. 1982; 24: 737-742https://doi.org/10.1177/001872088202400610
        • Nonnemaker J
        • Farrelly M
        • Kamyab K
        • Busey A
        • Mann N.
        Experimental study of graphic cigarette warning labels.
        Food and Drug Administration, Silver Spring, MD2020 (Published February. Accessed June 12, 2022)
        • Baig SA
        • Noar SM
        • Gottfredson NC
        • Boynton MH
        • Ribisl KM
        • Brewer NT.
        UNC Perceived Message Effectiveness: validation of a brief scale.
        Ann Behav Med. 2019; 53: 732-742https://doi.org/10.1093/abm/kay080
        • Brewer NT
        • Parada H
        • Hall MG
        • Boynton MH
        • Noar SM
        • Ribisl KM.
        Understanding why pictorial cigarette pack warnings increase quit attempts.
        Ann Behav Med. 2019; 53: 232-243https://doi.org/10.1093/abm/kay032
        • Noar SM
        • Barker J
        • Bell T
        • Yzer M.
        Does perceived message effectiveness predict the actual effectiveness of tobacco education messages? A systematic review and meta-analysis.
        Health Commun. 2020; 35: 148-157https://doi.org/10.1080/10410236.2018.1547675
        • Noar SM
        • Rohde JA
        • Prentice-Dunn H
        • Kresovich A
        • Hall MG
        • Brewer NT.
        Evaluating the actual and perceived effectiveness of E-cigarette prevention advertisements among adolescents.
        Addict Behav. 2020; 109106473https://doi.org/10.1016/j.addbeh.2020.106473
        • Bigsby E
        • Cappella JN
        • Seitz HH.
        Efficiently and effectively evaluating public service announcements: additional evidence for the utility of perceived effectiveness.
        Commun Monogr. 2013; 80: 1-23https://doi.org/10.1080/03637751.2012.739706
        • Himmelfarb S.
        What do you do when the control group doesn't fit into the factorial design?.
        Psychol Bull. 1975; 82: 363-368https://doi.org/10.1037/0033-2909.82.3.363
        • Curfman G.
        Graphic cigarette warning labels, the first amendment, and public right to accurate public health information: graphic cigarette warning labels back under legal scrutiny.
        JAMA Health Forum. 2021; 2e212886https://doi.org/10.1001/jamahealthforum.2021.2886
      9. Sodium Warning, §81.49, New York City (2015).https://docs.google.com/viewer?url=https%3A%2F%2Fwww1.nyc.gov%2Fassets%2Fdoh% 2Fdownloads%2Fpdf%2Fabout%2Fhealthcode%2Fhealth-code-article81.pdf. Accessed April 15, 2021.

      10. Sodium Safety Warning Labeling for Chain Establishments. §6-310, City of Philadelphia (2019).https://codelibrary.amlegal.com/codes/philadelphia/latest/philadelphia_pa/0-0-0-190525#JD_6-310. Accessed July 5, 2022.

        • Pham C
        • Rundle-Thiele S
        • Parkinson J
        • Li S.
        Alcohol warning label awareness and attention: a multi-method study.
        Alcohol Alcohol. 2018; 53: 39-45https://doi.org/10.1093/alcalc/agx087
        • Acton RB
        • Vanderlee L
        • Roberto CA
        • Hammond D.
        Consumer perceptions of specific design characteristics for front-of-package nutrition labels.
        Health Educ Res. 2018; 33: 167-174https://doi.org/10.1093/her/cyy006
        • Greenfield TK.
        Warning labels: evidence on harm reduction from long-term American surveys.
        in: Plant M Single E Stockwell T Alcohol: Minimizing the Harm. Free Association Books, London, United Kingdom1997: 105-125